Palliative Care

Oliver Hart

Welcome to the Palliative Care podcast. This episode aims to recap all of the important aspects of each topic so that you feel confident in your knowledge.

Alys Davies

We’ve split the episode into two parts. First, we will go through a topic breakdown. Then we will move into our rapid-recall question round, a section where we test your knowledge on the topics we have covered in the episode.

Oliver Hart

There are seven Palliative Care topics to cover in this episode, with tips dotted throughout.

Alys Davies

If you are using this podcast as revision for upcoming exams, please look on official websites for specifics on question weighting and structure. In this podcast, we will be explaining each topic through realistic clinical scenarios, similar to questions you’ll encounter in exams and real clinical situations.

Oliver Hart

So, let’s get started.

Alys Davies

Palliative care principles is our first topic, and it’s one that underpins every clinical decision in each topic that follows. Understanding what palliative care is and what it’s not, gives you the framework for answering questions about symptom management, prescribing, and advance care planning. There are three main principles tested in exams, which we’ll run through now.

Oliver Hart

First is how palliative care neither hastens nor postpones death. This is explicit WHO policy and is relevant to questions about opioid use, because a common misconception is that adequate opioid dosing for symptom control hastens death. It does not at therapeutic doses, and this principle underpins the legal and ethical justification for palliative prescribing.

Alys Davies

Second, palliative care applies from the point of diagnosis of a life-limiting condition, not just in the final days or hours. A patient with a cancer diagnosis or advanced heart failure should have palliative care involvement from the outset.

Oliver Hart

Third, it extends to families and continues through bereavement. In the community setting, the Gold Standards Framework is the primary tool for organising palliative care. It supports GPs and community nurses in identifying patients who may be in the last year of life, planning their care proactively, and ensuring out-of-hours teams have the information they need. The key identification tool within the GSF is the surprise question: would you be surprised if this patient died within the next year? It is not diagnostic, but it triggers action.

Alys Davies

Remember. Exams are likely to test for primary care responses to patients with declining function. A patient who triggers it should be placed on the palliative care register and should have an advance/proactive care plan initiated.

Oliver Hart

Now, we'll move to pain management. The framework for this is the WHO Analgesic Ladder, introduced in 1986. There are three steps, and the principle is to start at the appropriate step for the severity of pain and escalate if pain is not controlled. Step one is non-opioid analgesics, like paracetamol and NSAIDs. Step two is weak opioids, used for mild to moderate pain, such as codeine or tramadol. Step three is strong opioids, like morphine, oxycodone, or fentanyl. Adjuvants — such as gabapentin for neuropathic pain — can be added at any step, depending on the pain type.

Alys Davies

Morphine is the WHO's first-line strong opioid and the reference drug for this class. For an opioid-naive patient, the starting dose is oral morphine 5 to 10 mg every four hours. The breakthrough dose is one-sixth of the total daily dose, prescribed as required. If the patient needs three or more breakthrough doses in 24 hours, that is the signal to increase the regular dose, because the total daily requirement is higher than the current prescription.

Oliver Hart

The next layer is morphine metabolism. Morphine is metabolised in the liver to two main metabolites, M6G and M3G. M6G is pharmacologically active and provides analgesia. M3G is not analgesic but is neuroexcitatory, accumulation causes agitation, myoclonus, and hyperalgesia. Understanding this metabolite profile explains several clinical problems.

Alys Davies

Remember, both M6G and M3G accumulate because they are renally excreted. M6G accumulation causes excessive sedation and respiratory depression. M3G accumulation causes agitation and myoclonus. The management is opioid rotation to fentanyl or alfentanil, both are hepatically metabolised with no active renal metabolites. A patient on morphine who develops agitation and myoclonus in the context of renal impairment may have opioid toxicity from M3G accumulation, you may need to rotate the opioid to resolve this.

Alys Davies

Opioid rotation is used for two indications: intolerable side effects that are opioid-specific, or inadequate analgesia despite dose titration. When rotating, always check an equianalgesic conversion table and reduce the new opioid dose by 25 to 30% to account for incomplete cross-tolerance. The oral to subcutaneous conversion for morphine is 2:1, 30 millagram oral morphine per day equals 15 millagram subcutaneous per day. That conversion is needed for syringe driver calculations.

Oliver Hart

There are three side effects to anticipate and manage as part of routine opioid prescribing. Constipation is universal and does not resolve over time, so always co-prescribe a stimulant laxative. Nausea is common in the first one to two weeks and usually resolves as tolerance develops. Sedation is common on initiation and with dose increases. Respiratory depression at therapeutic analgesic doses is rare, do not allow fear of respiratory depression to lead to under-treating pain.

Alys Davies

Now, we’ll move on to nausea and vomiting. The key principle is mechanism-based prescribing, selecting the antiemetic based on the cause of the nausea, not prescribing empirically. Different causes trigger different receptors and respond to different drugs, so identifying the mechanism is the clinical decision.

Oliver Hart

Chemical or metabolic causes including opioids, hypercalcaemia, and uraemia, act via the chemoreceptor trigger zone. The CTZ is sensitive to circulating toxins, and the drug that targets it is haloperidol. Ondansetron is the alternative for chemotherapy-induced nausea, where 5-HT3 receptor activation is the dominant mechanism. Gastric stasis or poor motility, common in advanced cancer and as a consequence of opioid use, is managed with metoclopramide, which has both central dopamine antagonism and peripheral prokinetic action. An important caveat is that metoclopramide stimulates peristalsis, so it must not be used in complete bowel obstruction it will cause colic against a blocked bowel.

Alys Davies

Vestibular causes, motion-related nausea or labyrinthine disease respond to cyclizine, an H1 antihistamine and muscarinic antagonist. Cyclizine is also effective for nausea from raised intracranial pressure, where it is combined with dexamethasone, the steroid reduces cerebral oedema and the cyclizine manages the nausea. For refractory or mixed-cause nausea where the mechanism is unclear, levomepromazine is the broad-spectrum option. It has dopaminergic, histaminergic, and muscarinic antagonism, it covers multiple pathways, and is commonly used in syringe drivers for end-of-life nausea.

Oliver Hart

Remember, metoclopramide is contraindicated in complete bowel obstruction. Peristaltic stimulation against a blocked bowel causes pain and colic. In a case of obstruction, use cyclizine or haloperidol.

Oliver Hart

Next, we are looking at breathlessness and secretions, two symptoms that often co-occur in the final days of life and are managed through different mechanisms. Starting with breathlessness. The pharmacological treatment is low-dose opioids. Oral or subcutaneous morphine reduces the central respiratory drive and the subjective sensation of breathlessness. It is effective even in the absence of pain, and at appropriate doses it does not hasten death.

Alys Davies

Benzodiazepines, midazolam or lorazepam, address the anxiety component of breathlessness, which can become a self-reinforcing cycle. Non-pharmacological measures which have strong evidence are: a fan directed at the face stimulates cold receptors around the mouth and nose, and reduces the perception of breathlessness. Positioning the patient upright reduces the work of breathing.

Oliver Hart

Oxygen is often the first thing we reach for when a patient is struggling to breathe, but it’s important to understand that breathlessness and low oxygen levels are not the same thing. A patient can be extremely short of breath with a completely normal SpO2. If that is the case, their oxygen level is not the problem, and giving oxygen is not going to help them. Oxygen is only indicated when the patient is genuinely hypoxic, so when their SpO2 drops below 92%. If their sats are normal, not only does oxygen provide no measurable reduction in breathlessness, it can actually make things worse, causing discomfort from the mask and drying out the mouth and airways. That distinction between breathlessness and hypoxia is one that comes up directly in exams, so it is worth making sure it is clear in your mind.

Alys Davies

Remember. Opioids do not hasten death at appropriate therapeutic doses. This is supported by the principle of double effect and is consistent with GMC guidance. Withholding opioids from a breathless or pain-distressed dying patient because of a misconception about respiratory depression is poor practice and contradicts the evidence base.

Oliver Hart

Secretions, sometimes called the death rattle, is the sound produced by oropharyngeal secretions pooling in a patient who can no longer swallow or cough effectively, this tends to not be distressing for patients as they are usually unconscious at the time. Management involves repositioning the patient first to allow secretions to drain by gravity. If that is insufficient, anticholinergic medication to reduce secretion production.

Oliver Hart

There are two anticholinergic options. The first is hyoscine hydrobromide, which crosses the blood-brain barrier, which means it can cause confusion and agitation. It is less appropriate in patients who still have some level of consciousness or who have pre-existing cognitive impairment. The second is glycopyrronium, as it does not cross the blood-brain barrier and carries a much lower risk of central side effects, making it the preferred choice when cognitive clarity is a concern. Suctioning is not appropriate in dying patients, as it is invasive, distressing, and ineffective for secretions that are deep in the airway.

Alys Davies

Next, we move on to terminal agitation and restlessness. This is agitation that occurs in the final hours or days of life. The reason assessment for reversible causes comes first, before any sedating medication, is that agitation in a dying patient often has a treatable cause that, if identified, can be addressed without heavy sedation. Missing a reversible cause means the patient remains distressed when they do not need to be.

Oliver Hart

The reversible causes to check are: urinary retention, constipation, opioid toxicity, fear and psychological distress, and (in medication-induced causes) corticosteroids. If any of these are identified and addressed, agitation may resolve without pharmacological sedation.

Alys Davies

When reversible causes have been excluded or treated and agitation persists, pharmacological management is indicated. First-line is midazolam subcutaneously, either as a stat dose or as a continuous infusion via syringe driver. Midazolam is a short-acting benzodiazepine that reduces agitation and distress rapidly. For refractory agitation that does not respond to midazolam alone, levomepromazine is added which has broad sedative and antiemetic properties. Haloperidol is useful specifically when there is a psychotic element like persistent paranoia or hallucinations driving the agitation.

Oliver Hart

Remember. In palliative sedation, use medication proportionately to reduce consciousness and relieve refractory suffering; this is ethically and legally distinct from euthanasia. It is proportionate, symptom-directed, and does not aim to hasten death. The distinction between proportionate palliative sedation and deliberate life-shortening is a higher-order concept that may be tested in exams.

Alys Davies

Now, we’ll look at anticipatory prescribing. When a patient is recognised as being in the last days or weeks of life, medications are prescribed in advance for the five symptom domains most likely to arise. The purpose is to remove any delay between a symptom occurring and treatment being given, whether there GP is available or not. These prescriptions are written prospectively, held at the bedside or in the home, and used as required. The five anticipatory prescription domains are: 1. Pain: morphine or diamorphine SC. 2. Breathlessness: midazolam SC, or low-dose morphine. 3. Nausea: haloperidol SC or cyclizine SC. 4. Secretions: hyoscine hydrobromide SC or glycopyrronium SC. And 5. Agitation: midazolam SC, levomepromazine SC if refractory.

Oliver Hart

When the oral route is lost — due to dysphagia, persistent vomiting, unconsciousness, or poor absorption — anticipatory medications that were prescribed as stat doses need to be delivered continuously. That is where the syringe driver comes in. The syringe driver is a battery-operated device that delivers a continuous subcutaneous infusion of medication over 24 hours. It provides consistent symptom control without repeated injections, and it can combine multiple drugs in a single infusion.

Alys Davies

The drug choice for the syringe driver follows from the anticipatory prescriptions but with one difference: diamorphine is preferred over morphine for syringe drivers in the UK. The reason is solubility, diamorphine is significantly more soluble and can be delivered in a much smaller volume, which matters when multiple drugs are being combined in a single syringe. Drug compatibility must be checked before combining medications. Not all combinations are stable in the same syringe. The driver should be reviewed every 24 hours, with symptom burden reassessed and doses titrated accordingly.

Oliver Hart

Remember, a syringe driver is a clinical decision based on the loss of the oral route or the need for continuous infusion. It is not initiated automatically because a patient is dying. Prescribing a syringe driver should not be delivered prematurely when the oral route is still available and adequate.

Oliver Hart

The last topic we’ll cover today is the legal and advance care planning framework. This topic is examined both as standalone content and because it intersects with the Mental Capacity Act, which also appears in Geriatric Medicine in the context of dementia and deprivation of liberty. The four key documents are DNACPR, ReSPECT, ADRT, and LPA. You need to know what each one does, who makes the decision, and how they interact.

Alys Davies

Do Not Attempt Cardiopulmonary Resuscitation — or DNACPR – is a clinical decision made by the responsible clinician. The patient must be involved and informed wherever possible, but the decision itself belongs to the clinical team. A DNACPR order applies only to CPR, all other treatments and interventions remain available unless separately decided. This is a point of frequent misunderstanding: DNACPR does not mean not for treatment. Family members cannot override a DNACPR. It is not their decision, and they do not have a legal veto.

Oliver Hart

Recommended Summary Plan for Emergency Care and Treatment — or ReSPECT – builds on DNACPR by providing a broader framework. It has replaced DNACPR as the primary document in many UK trusts. Rather than just addressing CPR, it captures escalation decisions, treatment preferences, and the patient's own values and wishes. It creates a clinical recommendation based on a documented conversation between clinician and patient. Its primary purpose is communication across care settings, particularly at handover and for out-of-hours responders who may not know the patient.

Alys Davies

Advance Decision to Refuse Treatment — or ADRT – is the mechanism by which a patient with capacity can refuse a specific treatment in advance, for specific future circumstances. It is legally binding under the Mental Capacity Act 2005, which means a clinician must follow it if it is valid and applicable, even if they disagree. For it to be valid: the patient must have had capacity when it was made, it must be specific about the treatment refused and the circumstances, and it must not have been withdrawn. If the ADRT refuses life-sustaining treatment specifically, additional formality is required: it must be in writing, signed, witnessed, and include an explicit statement that it applies even if life is at risk.

Oliver Hart

And lastly, LPA (Lasting Power of Attorney) takes a different approach: instead of the patient specifying their own refusal in advance, they appoint a trusted person to make decisions on their behalf when they can no longer do so. A Health and Welfare LPA is activated only when the person lacks capacity. The attorney cannot override a decision made by a person who still has capacity. The LPA must be registered with the Office of the Public Guardian before it can be used. An attorney can consent to or refuse life-sustaining treatment only if that power is explicitly granted in the LPA document.

Alys Davies

Both the ADRT and LPA are grounded in the Mental Capacity Act 2005, which provides the overarching legal framework. Five principles underpin all decisions made for or about a person who may lack capacity. The five principles are: 1. Assume capacity unless established otherwise. 2. Take all practicable steps to support the decision before concluding capacity is absent. 3. An unwise decision does not equal lack of capacity. 4. Any act for a person lacking capacity must be in their best interests. 5. Choose the least restrictive option.

Oliver Hart

The four-stage functional capacity test establishes whether a person has capacity for a specific decision. Can the person understand the information relevant to the decision? Can they retain it long enough to make the decision? Can they use or weigh the information to reach a decision? Can they communicate that decision? Failing any one of those four stages means they lack capacity for that specific decision. Capacity is always decision-specific and time-specific. A person may have capacity for one decision and not another, and capacity can change.

Alys Davies

Remember. A valid and applicable ADRT refusing life-sustaining treatment is legally binding, even if family members or clinicians disagree. It overrides a best interests decision. If the ADRT does not meet the formal validity criteria for life-sustaining treatment refusal, it is not legally binding as an ADRT, though it remains a strong statement of wishes that should inform best interests decisions.

Alys Davies

Let’s move on to our rapid-recall.

Oliver Hart

This section is all about what you know, and quickly!

Alys Davies

We’ll ask you a question, give you a couple of seconds to answer, then give you the correct answer. Just try to shout out your answer in time!

Oliver Hart

Question 1. The WHO analgesic ladder has three steps. What is the second step?

Alys Davies

Step two on the WHO analgesic ladder is weak opioids, codeine or tramadol.

Oliver Hart

Question 2. Morphine is metabolised into two active metabolites. Which one provides analgesia?

Alys Davies

The answer is morphine-6-glucuronide, known as M6G, which provides analgesia. M3G is the other active metabolites wich causes neuroleptic effects and toxicity. Both accumulate in renal impairment, which is why morphine requires dose reduction or switching in patients with poor renal function.

Oliver Hart

Question 3. A patient feels nauseated after starting opioids. The cause is stimulation of the chemoreceptor trigger zone. What is the first-line antiemetic?

Alys Davies

The answer is haloperidol.

Oliver Hart

Patient 4. A patient has nausea caused by gut dysmotility. Which antiemetic should be used?

Alys Davies

In this case, metoclopramide, a prokinetic, should be used.

Oliver Hart

Question 5. What is the first-line pharmacological treatment for breathlessness in palliative care?

Alys Davies

The first pharmacological treatment is low-dose oral morphine. This reduces the sensation of breathlessness without significantly suppressing respiration at palliative doses.

Oliver Hart

Question 6. A patient is dying and has noisy secretions. What should be avoided?

Alys Davies

Suctioning should be avoided as it causes distress without improving the secretions, which are too deep to clear.

Oliver Hart

Question 7. What drug is first-line for terminal agitation?

Alys Davies

The answer is midazolam.

Oliver Hart

Question 8. Anticipatory prescribing covers five symptom domains. Name two.

Alys Davies

You could have said: pain, breathlessness, secretions, agitation, or nausea and vomiting.

Oliver Hart

Question 9. What does DNACPR stand for?

Alys Davies

DNACPR stands for Do Not Attempt Cardiopulmonary Resuscitation. This means that patients may not receive cardiopulmonary resuscitation. All other treatments, antibiotics, fluids, analgesia, remain clinical decisions made separately.

Oliver Hart

And lastly, Question 10. Name one of the five principles of the Mental Capacity Act.

Alys Davies

You could have said: assume capacity unless proven otherwise; support the person to make their own decision; an unwise decision does not mean lack of capacity; decisions made on behalf of someone who lacks capacity must be in their best interests; or the least restrictive option should always be chosen.

Oliver Hart

That is your Palliative Medicine rapid recall done.

Alys Davies

Thank you for joining us for this episode.

Oliver Hart

If you have any questions or would like to recap any of the topics we have gone through today, take a moment to look back over the module.

Alys Davies

We will see you in the next episode. Bye!